Search

IntroductionResearch on public health interventions to improve hypertension care and control in low-income and middle-income countries remains scarce. This study aims to evaluate the effectiveness and assess the process and fidelity of implementation of a multi-component intervention to reduce the gaps in hypertension care and control at a population level in low-income communes of Medellin, Colombia.Methods and analysisA multi-component intervention was designed based on international guidelines, cross-sectional population survey results and consultation with the community and institutional stakeholders. Three main intervention components integrate activities related to (1) health services redesign, (2) clinical staff training and (3) patient and community engagement. The effectiveness of the intervention will be evaluated in a controlled before-after quasi-experimental study, with two deprived communes of the city selected as intervention and control arms. We will conduct a baseline and an endline survey 2 years after the start of the intervention. The primary outcomes will be the gaps in hypertension diagnosis, treatment, follow-up and control. Effectiveness will be evaluated with the difference-in-difference measures. Generalised estimation equation models will be fitted considering the clustered nature of data and adjusting for potential confounding variables. The implementation process will be studied with mixed methods. Implementation fidelity will be documented to assess to which degree the intervention components were implemented as intended.Ethics and disseminationThe study protocol has been approved by the Ethics Research Committee of Metrosalud in Colombia (reference 1400/5.2), the Medical Ethics Committee of the Antwerp University Hospital (reference 18/40/424) and the Institutional Review Board of the Antwerp Institute of Tropical Medicine (reference 1294/19). We will share and discuss the study results with the community, institutional stakeholders and national health policymakers. We will publish them in national and international peer-reviewed scientific journals.Trial registration numberNCT05011838.

BackgroundA recurrent tuberculosis (TB) episode results from exogenous reinfection or relapse after cure. The use of genotyping allows the distinction between both.MethodsWe did a systematic review and meta-analysis, using four databases to search for studies in English, French and Spanish published between 1 January 1980 and 30 September 2020 that assessed recurrences after TB treatment success and/or differentiated relapses from reinfections using genotyping. We calculated person years of follow-up and performed random-effects model meta-analysis for estimating pooled recurrent TB incidence rates and proportions of relapses and reinfections. We performed subgroup analyses by clinical–epidemiological factors and by methodological study characteristics.FindingsThe pooled recurrent TB incidence rate was 2.26 per 100 person years at risk (95% CI 1.87 to 2.73; 145 studies). Heterogeneity was high (I2=98%). Stratified pooled recurrence rates increased from 1.47 (95% CI 0.87 to 2.46) to 4.10 (95% CI 2.67 to 6.28) per 100 person years for studies conducted in low versus high TB incidence settings. Background HIV prevalence, treatment drug regimen, sample size and duration of follow-up contributed too. The pooled proportion of relapses was 70% (95% CI 63% to 77%; I²=85%; 48 studies). Heterogeneity was determined by background TB incidence, as demonstrated by pooled proportions of 83% (95% CI 75% to 89%) versus 59% (95% CI 42% to 74%) relapse for studies from settings with low versus high TB incidence, respectively.InterpretationThe risk of recurrent TB is substantial and relapse is consistently the most frequent form of recurrence. Notwithstanding, with increasing background TB incidence the proportion of reinfections increases and the predominance of relapses among recurrences decreases.PROSPERO registration numberCRD42018077867

Optimal hypertension care and control at population level significantly reduces cardiovascular morbidity and mortality. The study objective was to measure the gaps in the diagnosis, care, and control of hypertension in residents of an urban community in Quito, Ecuador. A cross-sectional population-based study with a sample of 2160 persons was performed using a survey and direct blood pressure measurement. Logistical regression models were used for analyzing factors associated with the gaps, expressed as percentages. The prevalence of hypertension was 17.6% [CI 95% 17.3–17.9%]. The diagnosis gap was 6.1% [CI 95% 5.9–6.2%] among the entire population and 34.5% [CI 95% 33.7–35.3%] among persons with hypertension. No access gaps were detected; whereas the follow-up gap was 22.7% [CI 95% 21.8–23.6%] and control gap reached 43.5% [CI 95% 42.6–44.2%]. Results indicated that being male, older than 64 years, an employee, without health insurance, and not perceiving a need for healthcare, increased the risk of experiencing these gaps. Data showed appropriate access to health services and high coverage in the diagnosis was due to the application of a community and family healthcare model. Notwithstanding, we found significant gaps in the follow-up and control of hypertensive patients, especially among older males, which should warrant the attention of the Ministry of Health.

Contacts of pulmonary tuberculosis (TB) cases are at high risk of TB infection and progression to disease. Close and household contacts and those5 years old have the highest risk. Isoniazid preventive therapy (IPT) can largely prevent TB disease among infected individuals. International and Peruvian recommendations include TB contact investigation and IPT prescription to eligible contacts. We conducted a study in Lima, Peru, to determine the number of close and household contacts who were evaluated, started on IPT, and who completed it, and the factors associated to compliance with national guidelines.We conducted a longitudinal retrospective study including all TB cases diagnosed between January 2015 and July 2016 in 13 health facilities in south Lima. Treatment cards, TB registers and clinical files were reviewed and data on index cases (sex, age, smear status, TB treatment outcome), contact investigation (sex, age, kinship to the index case, evaluations at month 0, 2 and 6) and health facility (number of TB cases notified per year, proportion of TB cases with treatment success) were extracted. We tabulated frequencies of contact evaluation by contact and index case characteristics. To investigate determinants of IPT initiation and completion, we used generalised linear mixed models.A total of 2323 contacts were reported by 662 index cases; the median number of contacts per case was four (IQR, 2-5). Evaluation at month 0 was completed by 99.2% (255/257) of contacts5 and 98.1% (558/569) of contacts aged 5-19 years. Of 191 eligible contacts5 years old, 70.2% (134) started IPT and 31.4% (42) completed it. Of 395 contacts 5-19 years old, 36.7% (145) started IPT and 32.4% (47) completed it. Factors associated to not starting IPT among contacts5 years old were being a second-degree relative to the index case (OR 6.6 95CI% 2.6-16.5), not having received a tuberculin skin test (TST) (OR 3.9 95%CI 1.4-10.8), being contact of a smear-negative index case (OR 5.5 95%CI 2.0-15.1) and attending a low-caseload health facility (OR 2.8 95%CI 1.3-6.2). Factors associated to not starting IPT among 5-19 year-olds were age (OR 13.7 95%CI 5.9-32.0 for 16-19 vs. 5-7 years old), being a second-degree relative (OR 3.0 95%CI 1.6-5.6), not having received a TST (OR 5.4, 95%CI 2.5-11.8), being contact of a male index case (OR 2.1 95CI% 1.2-3.5), with smear-negative TB (OR 1.9 95%CI 1.0-3.6), and attending a high-caseload health facility (OR 2.1 95%CI 1.2-3.6). Factors associated to not completing IPT, among contacts who started, were not having received a TST (OR 3.4 95%CI 1.5-7.9 for5 year-olds, and OR 4.3 95%CI 1.7-10.8 for those 5-19 years old), being contact of an index case with TB treatment outcome other than success (OR 9.3 95%CI 2.6-33.8 for5 year-olds and OR 15.3 95%CI 1.9-125.8 for those 5-19 years old), and, only for those 5-19 years old, attending a health facility with high caseload (OR 3.2 95%CI 1.4-7.7) and a health facility with low proportion of TB cases with treatment success (OR 4.4 95%CI 1.9-10.2).We found partial compliance to TB contact investigation, and identified contact, index case and health facility-related factors associated to IPT start and completion that can guide the TB programme in increasing coverage and quality of this fundamental activity.Les contacts des cas de tuberculose (TB) pulmonaire présentent un risque élevé d'infection à la TB et d'évolution vers la maladie. Les contacts étroits et familiaux et ceux de moins de 5 ans sont les plus à risque. Le traitement préventif à l'isoniazide (TPI) peut largement prévenir la maladie TB chez les personnes infectées. Nous avons mené une étude à Lima, au Pérou, pour déterminer le nombre de contacts proches et familiaux qui ont été évalués, qui ont commencé le TPI et qui l'ont achevé, ainsi que les facteurs associés au respect des directives nationales. MÉTHODES: Etude longitudinal rétrospective de tous les cas de TB diagnostiqués entre janvier 2015 et juillet 2016 dans 13 établissements de santé dans le sud de Lima. Les cartes de traitement, les registres de TB et les dossiers cliniques ont été examinés et des données sur les cas indice, l’investigation des contacts et les établissements de santé ont été extraites. Nous avons tabulé les fréquences d'évaluation des contacts par les caractéristiques des contacts et des cas indice. Pour étudier les déterminants de l'initiation et de l'achèvement du TPI, nous avons utilisé des modèles linéaires mixtes généralisés. RÉSULTATS: Au total, 2.323 contacts ont été rapportés par 662 cas indice; 70,2% des contacts âgés de moins de 5 ans ont commencé le TPI et 31,4% l'ont terminé, tandis que 36,7% des contacts âgés de 5 à 19 ans ont commencé le TPI et 32,4% l'ont terminé. Les facteurs associés au fait de ne pas commencer ou de terminer le TPI étaient: être un parent de second degré du cas indice, ne pas avoir reçu le test tuberculinique, être le contact d'un cas indice à frottis négatif et fréquenter un établissement de santé à faible charge de travail pour les moins de cinq ans contre fréquenter un établissement de santé à charge de travail élevée pour les contacts plus âgés.Nous avons constaté une compliance partielle à l'enquête sur les contacts de la TB, et avons identifié les facteurs liés aux contacts, aux cas indice et aux établissements de santé associés au début et à la fin du TPI qui peuvent guider le programme de TB dans l'augmentation de sa couverture et de sa qualité.

Background Following earlier trials indicating that their potential in dengue vector control was constrained by housing structure, a large-scale cluster-randomized trial of insecticide treated curtains (ITCs) and water jar covers (ITJCs) was undertaken in Venezuela. Methods In Trujillo, Venezuela, 60 clusters (6223 houses total) were randomized so that 15 clusters each received either PermaNet insecticide-treated window curtains (ITCs), permanent insecticide-treated water storage jar covers (ITJCs), a combination of both ITCs and ITJCs, or no insecticide treated materials (ITMs). A further 15 clusters located at least 5km from the edge of the study site were selected to act as an external control. Entomological surveys were carried out immediately before and after intervention, and then at 6-month intervals over the following 27 months. The Breteau and House indices were used as primary outcome measures and ovitrap indices as secondary. Negative binomial regression models were used to compare cluster-level values of these indices between the trial arms. Results Reductions in entomological indices followed deployment of all ITMs and throughout the trial, indices in the external control arm remained substantially higher than in the ITM study arms including the internal control. Comparing the ratios of between-arm means to summarise the entomological indices throughout the study, the combined ITC+ITJC intervention had the greatest impact on the indices, with a 63% difference in the pupae per person indices between the ITC+ITJC arm and the internal control. However, coverage had fallen below 60% by 14-months post-intervention and remained below 40% for most of the remaining study period. Conclusions ITMs can impact dengue vector populations in the long term, particularly when ITCs and ITJCs are deployed in combination. Trial registration ClinicalTrials.gov ISRCTN08474420; www.isrctn.com.

Introduction:People with tuberculosis experience long-term health effects beyond cure, including chronic respiratory diseases. We investigated whether tuberculosis is a risk factor for subsequent lung cancer.Methods:We searched PubMed, Scopus, Cochrane, Latin American and Caribbean Health Sciences Literature and the Scientific Electronic Library Online for cohort and case–control studies providing effect estimates for the association between tuberculosis and subsequent lung cancer. We pooled estimates through random-effects meta-analysis. The study was registered in PROSPERO (CDR42020178362).Results:Out of 6240 records, we included 29 cohort and 44 case–control studies. Pooled estimates adjusted for age and smoking (assessed quantitatively) were hazard ratio (HR) 1.51 (95% CI 1.30–1.76, I2=81%; five studies) and OR 1.74 (95% CI 1.42–2.13, I2=59%; 19 studies). The occurrence of lung cancer was increased for 2 years after tuberculosis diagnosis (HR 5.01, 95% CI 3.64–6.89; two studies), but decreased thereafter. Most studies were retrospective, had moderate to high risk of bias, and did not control for passive smoking, environmental exposure and socioeconomic status. Heterogeneity was high.Conclusion:We document an association between tuberculosis and lung cancer occurrence, particularly in, but not limited to, the first 2 years after tuberculosis diagnosis. Some cancer cases may have been present at the time of tuberculosis diagnosis and therefore causality cannot be ascertained. Prospective studies controlling for key confounding factors are needed to identify which tuberculosis patients are at the highest risk, as well as cost-effective approaches to mitigate such risk.

Background Hypertension requires life-long medical care, which may cause economic burden and even lead to catastrophic health expenditure. Objective To estimate the extent of out-of-pocket expenditure for hypertension care at a population level and its impact on households’ budgets in a low-income urban setting in Colombia. Methods We conducted a cross-sectional survey in Santa Cruz, a commune in the city of Medellin. In 410 randomly selected households with a hypertensive adult, we estimated annual basic household expenditure and hypertension-attributable out-of-pocket expenditure. For socioeconomic stratification, we categorised households according to basic expenditure quintiles. Catastrophic hypertension-attributable expenditure was defined as out-of-pocket expenditure above 10% of total household expenditure. Results The average annual basic household expenditure was US dollars at purchasing power parity (USD-PPP) $12,255.59. The average annual hypertension-attributable out-of-pocket expenditure was USD-PPP $147.75 (95% CI 120.93–174.52). It was incurred by 73.9% (95% CI 69.4%-78.1%) of patients, and consisted mainly of direct non-medical expenses (76.7%), predominantly for dietary requirements prescribed as non-pharmacological treatment and for transport to attend health care consultations. Medical out-of-pocket expenditure (23.3%) was for the most part incurred for pharmacological treatment. Hypertension-attributable out-of-pocket expenditure represented on average 1.6% (95% CI 1.3%-1.9%) of the total annual basic household expenditure. Eight households (2.0%; 95% CI 1.0%-3.8%) had catastrophic health expenditure; six of them belonged to the two lowest expenditure quintiles. Payments related to dietary requirements and transport to consultations were critical determinants of their catastrophic expenditure. Conclusions Out-of-pocket expenditure for hypertension care is moderate on average, but frequent, and mainly made up of direct non-medical expenses. Catastrophic health expenditure is uncommon and affects primarily households in the bottom socioeconomic quintiles. Financial protection should be strengthened by covering the costs of chronic diseases-related dietary requirements and transport to health services in the most deprived households. Abbreviations NCDs: Non-communicable diseases; LMICs: Low and middle-income countries; WHO: World Health Organization; HTN: hypertension; CVDs: Cardiovascular diseases; OOPE: out-of-pocket expenditure; USD-PPP: US dollars at purchasing power parity; CI: Confidence interval

Objectives: To assess a multicomponent intervention to improve private practitioners (PPs) involvement in referral of presumptive pulmonary TB (PTB) cases to the Revised National TB Control Programme (RNTCP) for sputum examination. Methods: Randomised controlled trial. We randomly allocated all 189 eligible PPs in Tumkur city, South India, to intervention or control arm. The intervention, implemented between December 2014 and January 2016, included two sets of activities, one targeted at health system strengthening (building RNTCP staff capacity to collaborate with PPs, provision of feedback on referrals through SMS) and one targeted at intervention PPs (training in RNTCP, provision of referral pads and education materials and monthly visits to PPs by RNTCP staff). Crude and adjusted referral and PTB case-finding rate ratios were calculated with negative binomial regression. Results: PPs referred 836 individuals (548 from intervention and 169 from control arm PPs) of whom 176 were diagnosed with bacteriologically confirmed PTB. The proportion (95% confidence interval) of referring PPs [0.59 (0.49, 0.68) vs. 0.42 (0.32, 0.52) in the intervention and control arm, respectively], mean referral rate per PP-year [(5.7 (3.8, 8.7) vs. 1.8 (1.2, 2.8)] and smear-positive PTB case-finding rate per PP-year [(1.5 (0.9, 2.2) vs. 0.6 (0.3, 0.9)] were significantly higher in the intervention than the control arm. Stratifying by qualification, a statistically significant difference in the above indicators remained only among GPs and internists. Overall, surgeons, paediatricians and gynaecologists referred few patients. PP referrals contributed to 20% of the sputum smear positive PTB cases detected by RNTCP in Tumkur city (14% were from intervention arm PPs). Conclusions: We demonstrated the effectiveness of a health system-oriented intervention to improve PP's referrals of presumptive PTB cases to RNTCP.

El texto completo de este trabajo no está disponible en el Repositorio Académico UPC por restricciones de la casa editorial donde ha sido publicado. Objectives: Diagnosis of pleural tuberculosis (PT) is still a challenge, particularly in resource-constrained settings. Alternative diagnostic tools are needed. We aimed at evaluating the utility of Clinical Prediction Rules (CPRs) for diagnosis of pleural tuberculosis in Peru. Methods: We identified CPRs for diagnosis of PT through a structured literature search. CPRs using high-complexity tests, as defined by the FDA, were excluded. We applied the identified CPRs to patients with pleural exudates attending two third-level hospitals in Lima, Peru, a setting with high incidence of tuberculosis. Besides pleural fluid analysis, patients underwent closed pleural biopsy for reaching a final diagnosis through combining microbiological and histopathological criteria. We evaluated the performance of the CPRs against this composite reference standard using classic indicators of diagnostic test validity. Results: We found 15 eligible CPRs, of which 12 could be validated. Most included ADA, age, lymphocyte proportion and protein in pleural fluid as predictive findings. A total of 259 patients were included for their validation, of which 176 (67%) had PT and 50 (19%) malignant pleural effusion. The overall accuracy of the CPRs varied from 41% to 86%. Two had a positive likelihood ratio (LR) above 10, but none a negative LR below 0.1. ADA alone at a cut-off of ≥40 IU attained 87% diagnostic accuracy and had a positive LR of 6.6 and a negative LR of 0.2. Conclusion: Many CPRs for PT are available. In addition to ADA alone, none of them contributes significantly to diagnosis of PT. Revisión por pares

Objective: Information on the cost of implementing residual insecticide treatment (RIT) for Aedes control is scarce. We evaluated the incremental cost on top of intensive conventional routine activities of the Aedes control programme (ACP) in the city of Santiago de Cuba, Cuba. Methods: We conducted the cost analysis study in 2011-2012, from the perspective of the ACP. Data sources were bookkeeping records, activity registers of the Provincial ACP Centre and the accounts of an RIT implementation study in 21 clusters of on average four house blocks comprising 5180 premises. Results: The annual cost of the routine ACP activities was 19.66 US$ per household. RIT applications in rounds at 4-month intervals covering, on average, 97.2% and using 8.5g of delthametrine annually per household, cost 3.06 US$ per household per year. Delthametrine comprised 66.5% of this cost; the additional cost for deploying RIT comprised 15.6% of the total ACP routine cost and 27% of the cost related to routine adult stage Aedes control. Conclusions: The incremental cost of implementing RIT is high. It should be weighed against the incremental effect on the burden caused by the array of pathogens transmitted by Aedes. The cost could be reduced if the insecticide became cheaper, by limiting the number of yearly applications or by targeting transmission hot spots.

Background To determine the prevalence of hypertension treatment and control among hypertensive patients in the Cuban municipalities of Cardenas and Santiago and to explore the main associated predictors. Methods Cross-sectional study, with multistage cluster sampling, conducted between February 2012 and January 2013 in two Cuban municipalities. We interviewed and measured blood pressure in 1333 hypertensive patients aged 18 years or older. Hypertension control was defined as blood pressure lower than 140/90 mmHg. Results The mean age ± standard deviation (SD) of participants was 59.8 ± 14 years, the mean systolic and diastolic blood pressure ± SD was 130.0 ± 14.4 and 83.1 ± 9.0 mmHg respectively. The majority of patients (91, 95%CI 90–93) were on pharmacological treatment, 49% with a combination of 2 or more classes of drugs. Among diagnosed hypertensive patients 58% (95%CI 55–61) had controlled hypertension. There was no association between hypertension control and gender, age and socio-economic condition. Levels of hypertension control depended on health area and control furthermore was positively associated with post-primary education, not being obese and white ethnicity: adjusted Odds Ratio (95% CI) 1.71 (1.26–2.34), 1.43 (1.09–1.88) and 1.41 (1.09–1.81) respectively. Conclusions The observed figures are outstanding at the international level and illustrate that hypertension treatment and control are achievable in a resource-constrained setting such as Cuba. The country’s primary health care approach and social equity in access to health care can be seen as key determinants of this success. Nevertheless, there is still room for improvement, as over a third of patients did not have controlled hypertension.

Background Since 2006, the Peruvian National TB program (NTP) recommends voluntary counseling and testing (VCT) for all tuberculosis (TB) patients. Responding to the differential burden of both diseases in Peru, TB is managed in peripheral health facilities while HIV is managed in referral centers. This study aims to determine the coverage of HIV screening among TB patients and the characteristics of persons not screened. Methods From March 2010 to December 2011 we enrolled new smear-positive pulmonary TB adults in 34 health facilities in a district in Lima. NTP staff offered VCT to all TB patients. Patients with an HIV positive result were referred for confirmation tests and management. We interviewed patients to collect their demographic and clinical characteristics and registered if patients opted in or out of the screening. Results Of the 1295 enrolled TB patients, nine had a known HIV diagnosis. Of the remaining, 76.1% (979) were screened for HIV. Among the 23.9% (307) not screened, 38.4% (118) opted out of the screening. TB patients at one of the health care facilities of the higher areas of the district (OR = 3.38, CI 95% 2.17–5.28 for the highest area and OR = 2.82, CI 95% 1.78–4.49 for the high area) as well as those reporting illegal drug consumption (OR = 1.65, CI 95% 1.15–2.37) were more likely not to be screened. Twenty-four were HIV positive (1.9% of all patients 1295, or 2.4% of those screened). Of 15 patients diagnosed with HIV during the TB episode, ten were enrolled in an HIV program. The median time between the result of the HIV screening and the first consultation at the HIV program was 82 days (IQR, 32–414). The median time between the result of the HIV screening and antiretroviral initiation was 148.5 days (IQR 32–500). Conclusions An acceptable proportion of TB patients were screened for HIV in Lima. Referral systems of HIV positive patients should be strengthened for timely ART initiation.

Objectives: Diagnosis of tuberculous meningitis (TM) is a challenge in countries with a high burden of the disease and constrained resources and clinical prediction rules (CPRs) could be of assistance. We aimed t developing a CPR for diagnosis of TM in a Latin American setting with high tuberculosis incidence and a concentrated HIV epidemic. Methods: We enrolled adult patients with clinical suspicion of TM attending two hospitals in Lima, Peru. We obtained information on potential anamnestic, clinical and laboratory predictive findings that are easy to collect and promptly available. We independently diagnosed TM according to a composite reference standard that included a series of microbiological tests. We performed bivariate analysis and constructed a logistic regression model to select the predictive findings associated with TM. With the selected predictors included in the model, we developed a score-based CPR. We assessed its internal validity and diagnostic performance. Results: Of 155 analysed patients, 59 (38%) had TM. The CPR we derived includes three predictors: cough for 14 days or more, 10-500 cells in CSF and adenosine deaminase 6 U/l in CSF. It classifies patients into high-, moderate- or low-score groups and has an overall area under the ROC curve of 0.87. 59% of patients were assigned to either the high- or the low-score group, permitting prompt decision-making. In patients in the high-score group, it attains a positive likelihood ratio for TM of 10.6 and in patients with low scores, a negative likelihood ratio of 0.10. Bootstrap analysis indicated high internal validity. Conclusion: This CPR could support decision-making in patients with clinical suspicion of TM. External validation and further assessment of its clinical impact are necessary before application in other settings.

Objectives To estimate the proportion of tuberculosis cases attributable to recent transmission and the risk factors possibly associated with tuberculosis clustering. Methods Population-based study combining information from epidemiological investigation of tuberculosis cases notified to the National Tuberculosis Control Program in Havana, Cuba, in 2009 with the results of genotyping of Mycobacterium tuberculosis isolates with variable number tandem repeat of mycobacterial interspersed repetitive units (MIRU-VNTR) typing. Results Of 186 cases, 61 were genotyped: 33 patterns and five clusters with 19, 7, 3, 2 and 2 cases were found. The proportion of cases due to recent transmission was 45% (95% confidence interval 33–58%). Routine contact investigation failed to identify a substantial number of epidemiological links. A history of living in a closed setting was strongly associated with clustering. Conclusions The proportion of cases due to recent transmission in Havana in 2009 is high. The existing control measures in closed settings should be strengthened. A study on a larger number of cases and for a longer time period should be carried out to obtain more precise estimates. Further studies on the utility and cost-effectiveness of the addition of molecular epidemiology techniques to support the progress towards tuberculosis elimination in Cuba, a low-incidence resource-limited setting, are also needed. Objectifs Estimer la proportion de cas de tuberculose (TB) attribuables a une transmission recente et les facteurs de risque pouvant etre associes au regroupement de la TB. Methodes Etude basee sur la population, combinant les informations provenant d'une enquete epidemiologique des cas de TB notifies au programme national de lutte contre la TB a La Havane, a Cuba, en 2009, avec des resultats du genotypage des isolats de Mycobacterium tuberculosis par la methode MIRU-VNTR. Resultats Sur 186 cas, 61 ont ete genotypes: 33 profils et 5 regroupements avec 19, 7, 3, 2 et 2 cas ont ete trouves. La proportion des cas dus a une transmission recente etait de 45% (IC95%: 33 a 58). L'investigation systematique des contacts n'a pas permis d'identifier un nombre important de liens epidemiologiques. Le fait de vivre dans une zone fermee a ete fortement associe au regroupement. Conclusions La proportion de cas dus a une transmission recente a La Havane en 2009 est elevee. Les mesures de controle existantes dans les zones fermees devraient etre renforcees. Une etude portant sur un plus grand nombre de cas et sur une periode plus longue devrait etre effectuee afin d'obtenir des estimations plus precises. Des etudes supplementaires sur l'utilite et le rapport cout-efficacite de l'adoption des techniques d’epidemiologie moleculaire pour soutenir le progres vers l’elimination de la TB a Cuba, une zone a ressources limitees et a faible incidence sont egalement necessaires. Objetivos Calcular la proporcion de casos de tuberculosis atribuibles a una transmision reciente y los factores de riesgo posiblemente asociados con los conglomerados de tuberculosis. Metodos Estudio poblacional que combina informacion de estudios epidemiologicos de casos de tuberculosis notificados al programa nacional de control de la tuberculosis en La Habana, Cuba, en el 2009 con los resultados de genotipar aislados de Mycobacterium tuberculosis mediante el metodo MIRU-VNTR (numero variable de repeticiones en tandem de unidades repetitivas interespaciadas de micobacterias). Resultados De 186 casos, 61 fueron genotipados: se encontraron 33 patrones y 5 conglomerados con 19, 7, 3, 2 y 2 casos. La proporcion de casos debido a una transmision reciente era del 45% (intervalo de confianza del 95%: 33%-58%). La investigacion rutinaria de contactos no consiguio identificar un numero sustancial de conexiones epidemiologicas. El historial de vivir en un lugar cerrado estaba fuertemente relacionado con los conglomerados. Conclusiones La proporcion de casos por una transmision reciente en La Habana en el 2009 era alta. Las actuales medidas de control en lugares cerrados deberian mejorarse. Deberia llevarse a cabo un estudio con un mayor numero de casos y por un mayor periodo de tiempo para conseguir estimaciones mas precisas. Tambien son necesarios mas estudios sobre la utilidad y costo-efectividad de anadir tecnicas de epidemiologia molecular para apoyar el progreso hacia la eliminacion de la tuberculosis en Cuba, un lugar con baja incidencia y recursos limitados.

Effective participatory strategies in dengue control have been developed and assessed as small-scale efforts. The challenge is to scale-up and institutionalize these strategies within dengue control programs. We describe and critically analyze the diffusion process of an effective empowerment strategy within the Cuban Aedes aegypti control program, focusing on decision-making at the national level, to identify ways forward to institutionalize such strategies in Cuba and elsewhere. From 2005 to 2009, we carried out a process-oriented case study. We used participant observation, in-depth interviews with key informants involved in the diffusion process and document analysis. In a first phase, the data analysis was inductive. In a second phase, to enhance robustness of the analysis, emerging categories were contrasted with Rogers' five-stage conceptual model of the innovation-decision process, which was eventually used as the analytical framework. The diffusion of the empowerment strategy was a continuous and dynamic process. Adoption was a result of the perceived potential match between the innovative empowerment strategy and the performance gap of the Ae. aegypti control program. During implementation, the strategy was partially modified by top level Ae. aegypti control program decision-makers to accommodate program characteristics. However, structure, practices and organizational culture of the control program did not change significantly. Thus rejection occurred. It was mainly due to insufficient dissemination of know-how and underlying principles of the strategy by innovation developers, but also to resistance to change. The innovation-diffusion process has produced mitigated results to date, and the control program is still struggling to find ways to move forward. Improving the innovation strategy by providing the necessary knowledge about the innovation and addressing control program organizational changes is crucial for successful diffusion of empowerment strategies. Issues highlighted in this particular experience might be relevant in the innovation-diffusion process of other complex innovations within health systems.

BACKGROUND: There have been few studies of the natural history of Mycoplasma genitalium in women. We investigated patterns of clearance and recurrence of untreated M. genitalium infection in a cohort of female sex workers in Uganda. METHODS: Women diagnosed as having M. genitalium infection at enrollment were retested for the infection at 3-month intervals. Clearance of infection was defined as testing negative after having a previous positive result: persistence was defined as testing positive after a preceding positive test result, and recurrence as testing positive after a preceding negative test result. Adjusted hazard ratios for M. genitalium clearance were estimated using Cox proportional hazards regression. RESULTS: Among 119 participants infected with M. genitalium at enrollment (prevalence, 14%), 55% had spontaneously cleared the infection within 3 months; 83%, within 6; and 93%, within 12 months. The overall clearance rate was 25.7/100 person-years (pyr; 95% confidence interval, 21.4-31.0). HIV-positive women cleared M. genitalium infection more slowly than did HIV-negative women (20.6/100 pyr vs. 31.3/100 pyr, P = 0.03). The clearance rate was slower among HIV-positive women with CD4 counts less than 350/mL than among those with higher CD4 counts (9.88/100 pyr vs. 29.5/100 pyr, P

Avaliamos o rendimento diagnóstico da fibrobroncoscopia óptica no diagnóstico de tuberculose pulmonar com baciloscopia negativa em pacientes atendidos em um hospital de referência em Lima, Peru. Dos 611 pacientes submetidos ao procedimento, 140 (23%) foram diagnosticados com tuberculose com base nas amostras de LBA. Ser mais jovem e do sexo masculino foi associado a culturas positivas. Além disso, 287 pacientes realizaram baciloscopia de escarro após a broncoscopia, e os resultados aumentaram o rendimento diagnóstico em 22% em relação às amostras de LBA. Concluímos que amostras de LBA e de escarro pós-broncoscopia tiveram um bom rendimento diagnóstico nos pacientes com suspeita de tuberculose pulmonar com baciloscopia negativa. We evaluated the diagnostic yield of fiberoptic bronchoscopy for the diagnosis of smear-negative pulmonary tuberculosis in patients treated at a referral hospital in Lima, Peru. Of the 611 patients who underwent the procedure, 140 (23%) were diagnosed with tuberculosis based on the analysis of BAL samples. Being young and being male were significantly associated with positive cultures. In addition, 287 patients underwent post-bronchoscopic sputum smear testing for AFB, the results of which increased the diagnostic yield by 22% over that obtained through the analysis of BAL samples alone. We conclude that the analysis of BAL samples and post-bronchoscopic sputum samples provides a high diagnostic yield in smear-negative patients suspected of having pulmonary tuberculosis.

First-line health services with a primary health care approach are a strong trigger for adequate health-care-seeking behavior. Research on the association between prevalence of chronic diseases and acute illnesses and use of health services emphasizes the importance of socioeconomic determinants in such patterns of utilization. In a cross-sectional study of 408 families in Centro Habana, Cuba, home interviews were conducted between April and June 2010 to analyze socio-demographic determinants of acute and chronic health problems and use of formal health services. Bivariate and logistic regression models were used. 529 persons reported a chronic disease. During the previous month, 155 of the latter reported an exacerbation and 50 experienced an unrelated acute health problem. 107 persons without chronic diseases reported acute health problems. Age was the strongest determinant of chronic disease prevalence. Adult women and the elderly were more likely to report acute problems. Acute patients with underlying chronic disease used formal services more often. No socio-demographic variable was associated with services use or consultation with the family physician. While the family physician is defined as the system's entry-point, this was the case for only 54% of patients that had used formal services, thus compromising the physician's role in counseling patients and summarizing their health issues. The importance of chronic diseases highlights the need to strengthen the family physician's pivotal role. New economic policies in Cuba, stimulating self-employment and private initiative, may increase the strain on the exclusively public health care system. Still, the Cuban health system has demonstrated its ability to adapt to new challenges, and the basic premises of Cuba's health policy are expected to be preserved. Resumen: Los servicios de salud de primera línea, o aquellos centrados en la atención primaria, sirven como un fuerte inductor de comportamientos en la búsqueda de cuidados de salud. Estudios sobre la asociación entre la prevalencia de enfermedades crónicas y problemas agudos, y la utilización de servicios de salud, resaltan la importancia de los determinantes socioeconómicos en estos patrones de utilización. Como parte de un estudio transversal con 408 familias en el Centro Habana, Cuba, se realizaron entrevistas domiciliarias entre abril y junio de 2010 para analizar los determinantes sociodemográficos de los problemas de salud agudos y crónicos y el uso de los servicios de salud. Se utilizaron modelos bivariados y de regresión logística. 529 personas relataron la historia de la enfermedad crónica. Durante el mes anterior, 155 de ellas relataron una exacerbación de la enfermedad crónica, y 50 tuvieron algún problema agudo, no relacionado con la enfermedad crónica. 107 personas -sin enfermedad crónica- informaron de problemas agudos. La edad era el principal determinante en la presencia de una enfermedad crónica. Las mujeres adultas y los ancianos presentaban una probabilidad mayor de relatar problemas agudos. Los pacientes con una enfermedad crónica utilizaban los servicios de salud con mayor frecuencia. Ninguna variable sociodemográfica estuvo asociada a la utilización de los servicios o a la consulta con el médico de familia. Pese a que el médico de familia sea definido como la puerta de entrada al sistema de salud, esto ocurría en solamente un 54% de los pacientes que contactaron con los servicios de salud, por lo que se ve comprometido el papel del médico como consejero y punto de referencia principal sobre las cuestiones de salud de la población. La importancia de las enfermedades crónicas destaca la necesidad de fortalecer el papel esencial del médico de familia. Nuevas políticas económicas en Cuba, con estímulos para la autonomía laboral y la iniciativa privada, podrán aumentar la tensión sobre el sistema de salud exclusivamente público. No obstante, el sistema de salud cubano, ya mostró ser capaz de adaptarse a nuevos desafíos, y se espera que las premisas básicas de la política de salud cubana sean preservadas. Resumo: Os serviços de saúde de primeira linha, ou aqueles com uma abordagem de atenção primária, servem como indutor forte de comportamentos de busca de cuidados de saúde. Estudos sobre a associação entre a prevalência de doenças crônicas e problemas agudos e o uso de serviços enfatizam a importância dos determinantes socioeconômicos desses padrões de utilização. Como parte de um estudo transversal de 408 famílias em Centro Habana, Cuba, foram realizadas entrevistas domiciliares entre abril e junho de 2010 para analisar os determinantes sócio-demográficos dos problemas de saúde agudos e crônicos e do uso de serviços de saúde. Foram utilizados modelos bivariados e de regressão logística. Quinhentas e vinte e nove pessoas relatavam história de doença crônica. Durante o mês anterior, 155 delas relataram uma exacerbação da doença crônica e 50 tiveram algum problema agudo, não relacionado à doença crônica. Cento e sete pessoas sem doença crônica referiram problemas agudos. Idade era o principal determinante da presença de doença crônica. As mulheres adultas e os idosos apresentavam probabilidade maior de relatar problemas agudos. Pacientes com doença crônica utilizavam os serviços de saúde com maior frequência. Nenhuma variável sociodemográfica esteve associada à utilização dos serviços ou à consulta com o médico de família. Embora o médico de família seja definido como a porta de entrada ao sistema de saúde, isso ocorria em apenas 54% dos pacientes que contataram os serviços de saúde, portanto comprometendo o papel do médico como conselheiro e ponto focal das questões de saúde das pessoas. A importância das doenças crônicas enfatiza a necessidade de fortalecer o papel essencial do médico de família. Novas políticas econômicas em Cuba, com estímulo para a autonomia laboral e a iniciativa privada, poderão aumentar a tensão sobre o sistema de saúde exclusivamente público. No entanto, o sistema de saúde cubano já mostrou ser capaz de se adaptar a novos desafios, e espera-se que as premissas básicas da política de saúde cubana sejam preservadas.

During the 1990s, Cuba was able to overcome a severe crisis, almost without negative health impacts. This national retrospective study covering the years 1989–2000 analyses the country’s strategy through essential social, demographic, health process and health outcome indicators. Gross domestic product (GDP) diminished by 34.76% between 1989 and 1993. In 1994 slow recuperation started. During the crisis, public health expenses increased. The number of family doctors rose from 9.22 to 27.03 per 104 inhabitants between 1989 and 2000. Infant mortality rate and life expectancy exemplify a series of health indicators that continued to improve during the crisis years, whereas low birth weight and tuberculosis incidence are among the few indicators that suffered deterioration. GDP is inversely related to tuberculosis incidence, whereas the average salary is inversely related to low birth weight. Infant mortality rate has a strong negative correlation with the health expenses per inhabitant, the number of maternal homes, the number of family doctors and the proportion of pregnant women receiving care in maternal homes. Life expectancy has a strong positive correlation with health expenses, the number of nursing personnel and the number of medical contacts per inhabitant. The Cuban strategy effectively resolved health risks during the crisis. In times of serious socio-economic constraints, a well conceptualized public health policy can play an important role in maintaining the overall well-being of a population. Durant les annees 1990 Cuba a ete capable de surmonter une grave crise, presque sans impacts negatifs sur la sante. Cette etude nationale retrospective couvrant les annees 1989 a 2000, analyse la strategie du pays par des indicateurs essentiels sociaux, demographiques, de processus de sante et de resultats de sante. Le PIB a diminue de 34,76% entre 1989 et 1993. En 1994, une recuperation lente a commencee. Pendant la crise, les depenses de sante publique ont augmente. Le nombre de medecins de famille a augmente de 9,22 a 27,03 pour 104 habitants entre 1989 et 2000. Le taux de mortalite infantile et l’esperance de vie illustrent une serie d’indicateurs de sante qui ont continue de s’ameliorer au cours des annees de crise, alors que le faible poids de naissance et l’incidence de la tuberculose sont parmi les quelques indicateurs qui ont subi une deterioration. Le PIB est inversement proportionnel a l’incidence de la tuberculose, tandis que le salaire moyen est inversement proportionnel au faible poids de naissance. Le taux de mortalite infantile a une forte correlation negative avec les depenses de sante par habitant, le nombre de maternites, le nombre de medecins de famille et la proportion de femmes enceintes recevant des soins dans les maternites. L’esperance de vie a une forte correlation positive avec les depenses de sante, le nombre du personnel infirmier et le nombre de contacts medicaux par habitant. La strategie cubaine a resolu efficacement les risques de sante durant la crise. En periode de graves contraintes socio-economiques, une politique de sante publique bien conceptualisee peut jouer un role important dans le maintien du bien-etre global d’une population. Durante la decada de los 90s, Cuba fue capaz de sobreponerse a una crisis severa, practicamente sin impactos negativos sobre la salud. Este estudio nacional retrospectivo cubre los anos entre 1989 – 2000 y analiza la estrategia del pais mediante procesos sociales, demograficos y sanitarios esenciales, asi como indicadores de resultados sanitarios. El PNB disminuyo en 34.76% entre 1989 y 1993. En 1994 comenzo una lenta recuperacion. Durante la crisis, aumento el gasto publico en salud. El numero de medicos de familia aumento de 9.22 a 27.03 por 104 habitantes entre 1989 y 2000. La tasa de mortalidad infantil y la esperanza de vida son ejemplos de una serie de indicadores de salud que continuaron mejorando durante los anos de crisis, mientras que el bajo peso al nacer y la incidencia de tuberculosis son algunos de los pocos indicadores que sufrieron una desmejora. El PNB estaba inversamente relacionado con la incidencia de tuberculosis, mientras que el salario promedio estaba inversamente relacionado con el bajo peso al nacer. La tasa de mortalidad infantil tenia una fuerte correlacion negativa con el gasto sanitario por habitante, el numero de casas de maternidad, el numero de medicos de familia, y la proporcion de mujeres embarazadas siendo atendidas en casas de maternidad. La esperanza de vida presentaba una fuerte correlacion positiva con el gasto sanitario, el numero de personal de enfermeria y el numero de contactos medico por habitante. La estrategia cubana resolvio de forma efectiva los riesgos sanitarios durante la crisis. En momentos de serios recortes socio-economicos, una politica de sanidad publica bien concebida puede jugar un papel importante en el mantenimiento general del bienestar de la poblacion.

Current dengue vector control strategies, focusing on reactive implementation of insecticide-based interventions in response to clinically apparent disease manifestations, tend to be inefficient, short-lived, and unsustainable within the worldwide epidemiological scenario of virus epidemic recrudescence. As a result of a series of expert meetings and deliberations, a paradigm shift is occurring and a new strategy, using risk stratification at the city level in order to concentrate proactive, sustained efforts in areas at high risk for transmission, has emerged. In this article, the authors 1) outline this targeted, proactive intervention strategy, within the context of dengue epidemiology, the dynamics of its transmission, and current Aedes control strategies, and 2) provide support from published literature for the need to empirically test its impact on dengue transmission as well as on the size of disease outbreaks. As chikungunya and Zika viruses continue to expand their range, the need for a science-based, proactive approach for control of urban Aedes spp. mosquitoes will become a central focus of integrated disease management planning.Las estrategias actuales de control de vectores del dengue, centradas en la ejecución reactiva de intervenciones con insecticidas en respuesta a la aparición de cuadros clínicos evidentes de la enfermedad, suelen ser ineficientes, de duración limitada e insostenibles en el contexto epidemiológico mundial, caracterizado por la recrudescencia de las epidemias virales. Como resultado de una serie de reuniones y deliberaciones entre expertos, está en proceso un cambio de paradigma y ha surgido una nueva estrategia, que consiste en estratificar el riesgo de cada ciudad para concentrar y mantener los esfuerzos proactivos donde hay un alto riesgo de transmisión. En este artículo, los autores 1) describen esta estrategia de intervención específica y proactiva dentro del contexto de las características epidemiológicas del dengue, la dinámica de su transmisión y las estrategias actuales de control de

INTRODUCTION Information regarding the cost of implementing insecticide-treated curtains (ITCs) is scarce. Therefore, we evaluated the ITC implementation cost, in addition to the costs of intensive conventional routine activities of the Aedes control program in the city of Guantanamo, Cuba. METHODS A cost-analysis study was conducted from the perspective of the Aedes control program, nested in an ITC effectiveness trial, during 2009-2010. Data for this study were obtained from bookkeeping records and activity registers of the Provincial Aedes Control Programme Unit and the account records of the ITC trial. RESULTS The annual cost of the routine Aedes control program activities was US$16.80 per household (p.h). Among 3,015 households, 6,714 ITCs were distributed. The total average cost per ITC distributed was US$3.42, and 74.3% of this cost was attributed to the cost of purchasing the ITCs. The annualized costs p.h. of ITC implementation was US$3.80. The additional annualized cost for deploying ITCs represented 19% and 48.4% of the total cost of the routine Aedes control and adult-stage Aedes control programs, respectively. The trial did not lead to further reductions in the already relatively low Aedes infestation levels. CONCLUSIONS At current curtain prices, ITC deployment can hardly be considered an efficient option in Guantanamo and other comparable environments.

Objective To assess the economic cost of routine Aedes aegypti control in an at-risk environment without dengue endemicity and the incremental costs incurred during a sporadic outbreak. Methods The study was conducted in 2006 in the city of Guantanamo, Cuba. We took a societal perspective to calculate costs in months without dengue transmission (January–July) and during an outbreak (August–December). Data sources were bookkeeping records, direct observations and interviews. Results The total economic cost per inhabitant (p.i.) per month. (p.m.) increased from 2.76 USD in months without dengue transmission to 6.05 USD during an outbreak. In months without transmission, the routine Aedes control programme cost 1.67 USD p.i. p.m. Incremental costs during the outbreak were mainly incurred by the population and the primary/secondary level of the healthcare system, hardly by the vector control programme (1.64, 1.44 and 0.21 UDS increment p.i. p.m., respectively). The total cost for managing a hospitalized suspected dengue case was 296.60 USD (62.0% direct medical, 9.0% direct non-medical and 29.0% indirect costs). In both periods, the main cost drivers for the Aedes control programme, the healthcare system and the community were the value of personnel and volunteer time or productivity losses. Conclusions Intensive efforts to keep A. aegypti infestation low entail important economic costs for society. When a dengue outbreak does occur eventually, costs increase sharply. In-depth studies should assess which mix of activities and actors could maximize the effectiveness and cost-effectiveness of routine Aedes control and dengue prevention. Objectif: Evaluer le cout economique du controle de routine de l’Aedes aegypti dans un environnement a risque sans endemicite pour la dengue et les couts marginaux encourus lors d’une epidemie sporadique. Methodes: L’etude a ete menee en 2006 dans la ville de Guantanamo, a Cuba. Nous avons adopte une perspective societale pour calculer les couts dans les mois sans transmission de la dengue (janvier a juillet) et lors d’une epidemie (aout a decembre). Les sources des donnees etaient les registres, des observations directes et des interviews. Resultats: Le cout financier total par habitant (ph) par mois (pm) a augmente de 2,76 USD au cours des mois sans transmission de la dengue a 6,05 USD au cours d’une epidemie. Au cours des mois sans transmission, le programme de controle de routine de l’Aedes coutait 1,67 USD ph.pm. Les couts marginaux lors de l’epidemie ont ete engages principalement par la population et le secteur primaire/secondaire du systeme de soins de sante, et a peine par le programme de lutte antivectorielle (increments de 1,64; 1,44 et 0,21 UDS ph.pm, respectivement). Le cout total pour la prise en charge d’un cas de dengue hospitalise a ete estimea 296,60 USD (62,0% en couts directs medicaux, 9,0% en couts directs non medicaux et 29,0% en couts indirects). Dans les deux periodes, les principaux facteurs determinant les couts pour le programme de controle du genre Aedes, le systeme de soins de sante et la communauteetaient la valeur du personnel et le temps des benevoles ou les pertes en productivite. Conclusions: Des efforts intensifs pour maintenir basse l’infestation par Aedes aegypti entrainent d’importants couts economiques pour la societe. Lorsqu’une epidemie de dengue arrive eventuellement, les couts augmentent fortement. Des etudes approfondies doivent evaluer quels types de combinaisons d’activites et d’acteurs peuvent maximiser l’efficacite et la rentabilite du controle de routine de l’Aedes et la prevention de la dengue. Objetivo: Evaluar el coste economico del control rutinario de Aedes aegypti en un ambiente de riesgo sin dengue endemico y los costes incrementales incurridos durante un brote esporadico. Metodos: El estudio se realizo en el 2006 en la ciudad de Guantanamo, Cuba. Se utilizo una perspectiva social para calcular los costes en meses sin transmision del dengue (Enero a Julio) y duriante el brote (Agosto-Diciembre). Las fuentes de datos fueron libros de registro, la observacion directa y entrevistas. Resultados: El coste economico total por habitante (p.h.) por mes (p.m.) aumento de 2.76 USD en meses sin transmision del dengue al 6.05 USD durante un brote. En meses sin transmision el programa de control rutinario de Aedes cuesta 1.67 USD p.i. p.m. Los costes incrementales durante el brote eran principalmente para la poblacion y para los niveles primario/secundario del sistema sanitario, casi nunca para el programa de control vectorial (1.64, 1.44 y 0.21 UDS aumento p.h. p.m., respectivamente). El coste total de manejar un caso hospitalizado con sospecha de dengue era de 296.60 USD (62.0% costes medicos directos, 9.0% costes directos no medicos y 29.0% costes indirectos). En ambos periodos, los principales factores de coste para el programa de control de Aedes, para el sistema de cuidados sanitarios y para la comunidad eran el coste del personal y el tiempo de voluntarios, o perdidas de productividad. Conclusiones: Los intensos esfuerzos para mantener bajos los niveles de infestacion de Aedes aegypti conllevan a importantes costes economicos para la sociedad. Cuando eventualmente ocurre un brote de dengue, los costes aumentan considerablemente. Estudios en profundidad deberian evaluar cual mezcla de actividades y actores podria maximizar la efectividad y la costo-efectividad del control rutinario de Aedes y de la prevencion del dengue.

During the dengue outbreak that struck Santiago de Cuba in 2006-2007, we conducted an observational study in the Mariana Grajales district, the former setting of a community trial for Aedes aegypti control. In the trial, community working groups (CWG) had been created in 29 randomly selected intervention house blocks, and routine vector control activities alone were conducted in the remaining 30 control blocks. The CWG elaborated and implemented with the population plans and activities to reduce Aedes infestation. They were still functional in 2006 and continued organizing community-based environmental management activities. The attack rate of dengue fever during the outbreak was 8.5 per 1000 inhabitants in the former intervention blocks and 38.1 per 1000 inhabitants in the control blocks, which corresponds to a relative risk of 4.5 (95% CI 3.1-6.5). There was a significantly higher proportion of unaffected intervention blocks, and affected blocks had on average substantially less cases than affected control blocks. This study indicates that community-based environmental management inserted in the routine A. aegypti control programme can not only sustainably curb vector infestation but also have an impact on dengue transmission.

Summary Objective To evaluate the performance of an algorithm based on WHO recommendations for diagnosis of smear-negative pulmonary tuberculosis in HIV-negative patients. Methods We recruited HIV-negative patients with clinical suspicion of tuberculosis who had had three negative sputum smears in Lima, Peru. All included subjects underwent a complete anamnesis, physical examination and chest X-ray, and had a sputum specimen cultured in Ogawa, Middlebrook 7H9 media and MGIT®. We applied an algorithm based on WHO recommendations to classify patients as having tuberculosis or not. The diagnostic performance of the algorithm was evaluated comparing its results against the reference standard of a positive culture for M. tuberculosis in either of the media used. Results A total of 264 of the 285 patients included (92.6%) completed evaluation and follow up. Of these, 70 (26.5%) had a positive culture for M. tuberculosis. Clinical response to a broad spectrum course of antibiotics was good in 32 of these 70 patients (45.7; 95%CI 34.0–57.4%). Overall, the algorithm attained a sensitivity of 22.9% (95% CI 13.1–32.7%) and a specificity of 95.4 % (95% CI 92.4–98.3%) compared to culture results. The positive likelihood ratio was 4.93 and the negative likelihood ratio was 0.81. Conclusions The sensitivity and negative likelihood ratio of the algorithm is poor. It should be re-evaluated, and possibly adapted to local circumstances before further use. The clinical response to an antibiotic trial is the most important component to reassess. We also suggest considering performing chest X-ray earlier in the diagnostic work-up. Performance d’un algorithme base sur les recommandations de l’OMS pour le diagnostic de la tuberculose pulmonaire a frottis negatif chez les patients non infectes par le VIH Objectif: Evaluer la performance d’un algorithme base sur les recommandations de l’OMS pour le diagnostic de la TB pulmonaire a frottis negatif chez les patients VIH-negatifs. Methodes: Nous avons recrute des patients VIH-negatifs avec une suspicion clinique de TB et avec 3 frottis negatifs, a Lima au Perou. Tous les sujets inclus ont subi une anamnese complete, un examen physique et une radiographie du thorax et ont eu un echantillon d’expectoration cultive sur milieux Ogawa, Middlebrook 7H9 et MGIT®. Nous avons applique un algorithme base sur les recommandations de l’OMS pour classer les patients comme ayant la TB ou non. Les performances diagnostiques de l’algorithme ont eteevaluees en comparant les resultats avec la norme de reference d’une culture positive pour M. tuberculosis sur un des milieux utilises. Resultats: 264 des 285 patients inclus (92,6%) ont complete l’evaluation et le suivi. De ceux-ci, 70 (26,5%) avaient une culture positive pour M. tuberculosis. La reponse clinique a un regime d’antibiotiques a large spectre a ete bonne chez 32 de ces 70 patients (45,7; IC95%: 34,0–57,4). Dans l’ensemble, l’algorithme a atteint une sensibilite de 22,9% (IC95%: 13,1-32,7) et une specificite de 95,4% (IC95%: 92,4-98,3) comparativement aux resultats de la culture. Le rapport de prediction positive etait de 4,93 et le rapport de prediction negative 0,81. Conclusions: La sensibilite et le rapport de prediction negative de l’algorithme sont faibles. Ils devraient etre reevalues et eventuellement adaptes aux circonstances locales avant une nouvelle utilisation. La reponse clinique a un essai aux antibiotiques est l’element le plus important a reevaluer. Nous suggerons aussi d’envisager l’utilisation de la radiographie du thorax plus tot dans le bilan diagnostique. Desempeno de un algoritmo basado en las recomendaciones de la OMS para el diagnostico de la tuberculosis pulmonar con baciloscopia negativa en pacientes sin infeccion por VIH Objetivo: Evaluar el desempeno de un algoritmo basado en las recomendaciones de la OMS para el diagnostico de la tuberculosis pulmonar con baciloscopia negativa en pacientes VIH negativos. Metodos: Hemos reclutado pacientes VIH negativos con sospecha clinica de tuberculosis que tenian 3 esputos negativos en Lima, Peru. Todos los sujetos incluidos fueron sometidos a una anamnesis completa, examen fisico y placa de torax, asi como un cultivo de esputo en Ogawa, medio Middlebrook 7H9 y MGIT®. Aplicamos el algoritmo basado en las recomendaciones de la OMS para clasificar los pacientes como con o sin TB. El desempeno del algoritmo en cuanto al diagnostico se evaluo comparando sus resultados frente a los del estandar de referencia de un cultivo positive de M. tuberculosis en cualquiera de los medios utilizados. Resultados: 264 de los 285 pacientes incluidos (92.6%) completaron la evaluacion y el seguimiento. De estos, 70 (26.5%) tenian un cultivo positivo para M. tuberculosis. La respuesta clinica al tratamiento con antibioticos de amplio espectro era buena en 32 de estos 70 pacientes (45.7; 95%IC 34.0-57.4%). En general, el algoritmo alcanzo una sensibilidad de 22.9% (95% IC 13.1- 32.7%) y una especificidad del 95.4% (95% IC 92.4-98.3%) comparado con los resultados del cultivo. La razon de verosimilitud positiva era 4.93 y la razon de verosimilitud negativa era 0.81. Conclusiones: La sensibilidad y la razon de verosimilitud negativa del algoritmo son pobres. Deberia reevaluarse, y a ser posible adaptarse a las circunstancias locales antes de continuar siendo utilizado. La respuesta clinica de un ensayo de antibioticos es el componente mas importante a ser reevaluado. Tambien sugerimos considerar el realizar una placa de torax mas temprano en el diagnostico.

OBJECTIVE: Identify Cuban municipalities with high, medium, and low incidence of tuberculosis (TB), compare incidence rates for the periods 1999-2002 and 2003-2006, and analyze distribution of the disease by population density and economic activity. METHODS: TB incidence was calculated by municipality, confidence interval (95%), and the percentage of variation for the defined strata according to population density and the predominant economic activity. The municipalities were divided into three categories based on incidence (> 10 per 100 000; > 5 per 100 000 to < 10 per 100 000, and < 5 per 100 000), and maps were plotted. RESULTS: The proportion of municipalities with an incidence of < 5 per 100 000 rose from 35.5% to 57.4% between the two periods, while the proportion of municipalities with an incidence of > 10 per 100 000 fell from 22.5% to 5.9%. National incidence fell by 28.7%-from 8.7 per 100 000 in 1999-2002 to 6.2 in 2003-2006. Municipalities that were not very densely populated and where agricultural activities predominated showed significant reductions in incidence. The rates in densely populated municipalities devoted primarily to industrial and service activities are still high. CONCLUSIONS: TB incidence is gradually and sustainably declining in the majority of municipalities. Differentiated strategies are needed to reduce TB incidence rates in municipalities where they continue to be relatively high.

Summary Objective To compare the yield of active tuberculosis (TB) case detection among risk groups during home visits with passive detection among patients at health services. Methods In April 2004, in a first phase, we introduced, active screening for coughing among all family members of patients that were visited at home by their family doctor or nurse for other reasons. Subsequently, from October 2004 onwards, active screening was restricted to family members belonging to groups at risk of TB. Results The overall detection rate of TB increased from 6.7/100 000 during passive detection at health services before the intervention to 26.2/100 000 inhabitants when passive detection was complemented by active case finding. Active screening among risk groups yielded 35 TB cases per 1000 persons screened compared to 20 TB cases per 1000 persons passively screened at health services. Active case finding was particularly efficient in those coughing for 3 weeks or more (107/1000 screened). Conclusion This study demonstrates that active case finding in groups at risk during home visits increases the case detection rate in the population and permits the identification of cases that may not be detected through passive case finding at health facility level. Objectif: Comparer le rendement de la detection des cas de TB active dans les groupes a risque au cours de visites a domicile avec celui de la detection passive chez les patients dans des services de sante. Methodes: En avril 2004, dans une premiere phase, nous avons introduit le depistage actif en cas de toux chez tous les membres de la famille des patients, visites a domicile par leur medecin de famille ou par une infirmiere pour d’autres raisons. Ensuite, a partir d’octobre 2004, le depistage actif a ete limite aux membres de la famille appartenant a des groupes a risque de TB. Resultats: Le taux de detection globale de la TB a augmente, passant de 6,7/100000 au cours de detection passive dans les services de sante avant l’intervention a 26,2/100000 habitants lorsque la detection passive a ete complementee par la detection active des cas. Le depistage actif chez les groupes a risque a identifie 35 cas de TB pour 1000 personnes examinees par rapport a 20 cas de TB pour 1000 personnes passivement examinees dans les services de sante. La detection active des cas a ete particulierement efficace dans les toux de trois semaines ou plus (107/1000 examines). Conclusion: Cette etude demontre que la detection active des cas dans les groupes a risque au cours de visites a domicile augmente le taux de detection des cas dans la population et permet l’identification de cas qui ne peuvent pas etre detectes par la recherche passive des cas au niveau des services de sante. Objetivo: Comparar el rendimiento de deteccion de casos activos de TB entre grupos de riesgo durante visitas domiciliarias con deteccion pasiva entre pacientes de los servicios sanitarios. Metodos: En Abril 2004, durante una primera fase, introdujimos el tamizaje activo para tos entre todos los miembros de las familias de pacientes que recibian visitas domiciliarias de su medico de familia o enfermeras por cualquier otro motivo. A partir de Octubre 2004 y en adelante, el tamizaje activo estuvo restringido a los miembros de familias pertenecientes a grupos de riesgo de TB. Resultados: La tasa de deteccion total de TB aumentaba de 6.7/100,000 durante la deteccion pasiva en los servicios sanitarios antes de la intervencion a 26.2/100,000 habitantes cuando la deteccion pasiva era complementada con la busqueda activa de casos. El tamizaje activo entre grupos de riesgo dio 35 casos de TB por 1,000 personas tamizadas, comparado con 20 casos de TB por 1,000 personas tamizadas de forma pasiva en los servicios sanitarios. El hallazgo activo de casos fue particularmente eficiente en aquellos que llevaban tosiendo tres semanas o mas (107/1000 tamizados). Conclusion: Este estudio demuestra que el hallazgo activo de casos en grupos de riesgo durante visitas domiciliarias aumenta la tasa de deteccion de casos en una poblacion y permite la identificacion de casos que podrian no ser detectados mediante la busqueda pasiva a nivel de centros sanitarios.

Community Health Insurance (CHI) in Uganda faces low enrolment despite interest by the Ugandan health sector to have CHI as an elaborate health sector financing mechanism. User fees have been abolished in all government facilities and CHI in Uganda is limited to the private not for profit sub-sector, mainly church-related rural hospitals. In this study, the reasons for the low enrolment are investigated in two different models of CHI. Focus group discussions and in-depth interviews were carried out with members and non-members of CHI schemes in order to acquire more insight and understanding in people's perception of CHI, in their reasons for joining and not joining and in the possibilities they see to increase enrolment. This study, which is unprecedented in East Africa, clearly points to a mixed understanding on the basic principles of CHI and on the routine functioning of the schemes. The lack of good information is mentioned by many. Problems in ability to pay the premium, poor quality of health care, the rigid design in terms of enrolment requirements and problems of trust are other important reasons for people not to join. Our findings are grossly in line with the results of similar studies conducted in West Africa even if a number of context-specific issues have been identified. The study provides relevant elements for the design of a national policy on CHI in Uganda and other sub-Saharan countries.

Basandose en ejemplos concretos de sistemas de salud, se aportan elementos y argumentos al debate internacional sobre la importancia de los niveles de atencion y de la relacion optima entre niveles. El primer nivel tiene tres funciones esenciales: ser el punto de entrada al sistema, facilitar y coordinar el itinerario de su paciente en el sistema, y asegurar la integracion y la sintesis de la informacion de salud de cada paciente. Describiendo los diferentes obstaculos y problemas posibles, en primer lugar la logica comercial que se ha ido introduciendo en muchos sistemas, los autores definen puntos de atencion y proponen ajustes para asegurar el acceso universal, la equidad, la eficacia y eficiencia, y la sostenibilidad de un sistema de salud.

Summary Background Indonesia has a high tuberculosis (TB) prevalence and a large private health sector. Objectives To explore the potential of private practitioners (PP) in TB control in Jogjakarta by assessing their load of TB suspects and case-management practices. Methods We conducted a cross-sectional telephone survey of a random sample of 164 PP, weighted to the local proportions of specialists, general practitioners (GP), nurses and midwives. We investigated their knowledge of directly observed treatment, short-course (DOTS), whether they see TB suspects, whether they refer such patients and how they possibly diagnose and treat TB. Results We sampled 174 PP, of which 164 (94.3%) completed the interview. Most PP (63.4%) reported to have seen TB suspects in their private practice, and 62.8% were also employed in a DOTS facility. Specialists saw on average 18 suspects, GP 11 suspects, and nurses–midwives three suspects in a year. Many PP (45.2%) always relied on National Tuberculosis Control Programme (NTP) services for diagnosis. Fewer PP (41.5%) used, by themselves, diagnostic procedures complying with the NTP guidelines. The majority (63.6%) always referred confirmed cases for treatment, mainly (71.4%) to NTP services. Most PP (72.7%) who treated TB patients themselves did not prescribe the NTP standard regimen. Conclusion The study shows that the TB case load per PP is low in Jogjakarta, where the NTP already involves public and private hospitals besides public health centres. Initiatives to engage all PP might only marginally contribute in increasing the TB case detection. Donnees de base L’Indonesie a une prevalence elevee de tuberculose (TB) et un vaste secteur prive de sante. Objectifs Explorer le potentiel des praticiens prives (PP) dans le controle de la TB a Jogjakarta en evaluant la charge de suspects TB dans leur clientele et les pratiques de gestion des cas de TB. Methodes Nous avons mene une surveillance transversale par telephone sur un echantillon aleatoire de 164 PP ponderes aux proportions locales de specialistes, de medecins generalistes, d’infirmieres et de sages-femmes. Nous avons investigue leur connaissance du DOTS (administration du schema court de traitement sous observation), s’ils voyaient des suspects TB, s’ils referaient de tels patients et comment ils diagnostiquaient et traitaient la TB. Resultats Sur un echantillons de 174 PP, 164 (94,3%) ont accompli l’entretien. La plupart des PP (63,4%) ont rapporte avoir vu des suspects TB dans leur cabinet prive et 62,8%etaient egalement employes dans un service DOTS. Les specialistes avaient vu en moyenne 18 suspects, les medecins generalistes 11 suspects et les infirmieres/sages-femmes, 3 suspects en une annee. Beaucoup de PP (45,2%) se sont toujours bases sur les services des programmes nationaux de controle de la tuberculose (PNT) pour le diagnostic. Peu de PP (41,5%) ont employe par eux-memes des procedures de diagnostic conformes aux directives des PNT. La majorite (63,6%) des PP ont toujours refere les cas confirmes de TB pour traitement, principalement (71,4%) dans les services de PNT. La plupart des PP (72,7%) qui ont eux-memes traite des patients TB n’ont pas prescrit le regime standard du PNT. Conclusion L’etude montre que la charge de cas de TB par pp est faible a Jogjakarta ou le PNT implique deja les hopitaux publics et prives autant que les centres de sante publique. Les initiatives pour engager tout les PP pourraient contribuer, mais seulement marginalement, a augmenter la detection de cas de TB. Antecedentes Indonesia tiene una alta prevalencia de tuberculosis (TB) y un amplio sector sanitario privado. Objetivos Explorar el potencial que los medicos con consultas privadas (MPs) tendrian en el control de la TB en Yogyakarta, evaluando su papel en la carga de sospecha de TB y practica de manejo de casos. Metodos Se realizo un estudio telefonico croseccional a una muestra de 164 MPs elegida al azar y ponderada por la proporcion de especialistas, medicos generales, enfermeras y comadronas. Se evaluo su conocimiento de DOTS (terapia de observacion directa), si atiendian pacientes con sospecha de TB, si refierian a dichos pacientes y como podrian diagnosticarse y tratarse la TB. Resultados De una muestra de 174 MPs, 164 (94.3%) completaron la entrevista. La mayoria de los MPs (63.4%) reportaron haber visto casos con sospecha de TB en sus consultas privadas y 62.8% estaban tambien empleados en un centro que utilizaba DOTS. En promedio, los especialistas veian 18 sospechosos por ano, los medicos generales 11, y las enfermeras y comadronas 3. Muchos MPs (45.2%) dependian siempre del Programa Nacional de Tuberculosis (PNT) para servicios de diagnostico. Un menor numero de MPs (41.5%) utilizaban, ellos solos, procedimientos diagnosticos que cumpliesen con las guias del PNT. La mayoria (63.6%) siempre referia los casos confirmados para tratamiento, principalmente (71.4%) a los servicios del PNT. La mayoria de los MPs (72.7%) que trataban ellos mismos a los pacientes con TB no prescribian el regimen estandar del PNT. Conclusion El estudio muestra que la carga de casos de TB por MP es baja en Yogyakarta, en donde el PNT ya involucra hospitales publicos y privados ademas de centros sanitarios publicos. Las iniciativas para implicar a todos los MPs podria contribuir a aumentar solo marginalmente la deteccion de casos de TB.

In the first years after Cuba's 1959 revolution, the island's new government provided international medical assistance to countries affected by natural disasters or armed conflicts. Step by step, a more structural complementary program for international collaboration was put in place. The relief operations after Hurricane Mitch, which struck Central America in 1998, were pivotal. From November 1998 onward, the “Integrated Health Program” was the cornerstone of Cuba's international cooperation. The intense cooperation with Hugo Chávez's Venezuela became another cornerstone. Complementary to the health programs abroad, Cuba also set up international programs at home, benefiting tens of thousands of foreign patients and disaster victims. In a parallel program, medical training is offered to international students in the Latin American Medical School in Cuba and, increasingly, also in their home countries. The importance and impact of these initiatives, however, cannot and should not be analyzed solely in public health terms.

Summary Considerable efforts were made in Guatemala to cover rural areas with health centres, and health programmes have been launched to treat and prevent the most important childhood diseases. Despite this, the utilization rate of public health services has reportedly been low throughout the past two decades. How, and how effectively, do mothers resolve the health problems of their children? To gain better insight into health care behaviour, we conducted a health services utilization survey in two highland communities in the department of Sacatepequez in 1992–1993. We asked 324 mothers in two villages whether, and where, they had sought help the last time their children under 5 years of age had suffered from diarrhoea, fever, cough symptoms or worms. Mothers relied on home care in 63–83% of reported episodes and the use of health services—Western or traditional—was consistently low. Although Western health care was easily accessible, it was used in only 8–15% of cases. The only identifiable significant independent determinants of utilization were occupational status of the mother (RR=1.5 if employed) and overall level of socioeconomic development of the community (RR=1.7). Inquiry into treatments used revealed that except for worms, which were frequently treated with herbs (31%) or external remedies (20%) alone, modern pharmaceuticals predominated. Antibiotics were the remedy of choice against diarrhoea (63%), antipyretics in case of fever (83%) and cough syrups with expectorants or antitussives against cough (65%). One hundred and twenty-one of the children born after 1975 died; in only 64 cases (53%) was a Western health service consulted between onset of disease and death. No relation was found between attendance and socioeconomic characteristics of the parents, but a positive linear association between duration of the fatal illness episode and age of the child could be identified. Independent sources report a drop in infant mortality of 53 and 35% respectively in the two communities between 1977 and 1991. Our findings seem to indicate that this reduction was achieved despite under-utilization of Western health services.

For decades, two opposing logics have dominated the health policy debate: a comprehensive health care approach, with the 1978 Alma Ata Declaration as its cornerstone, and a private competition logic, emphasizing the role of the private sector. We present this debate and its influence on international health policies in the context of changing global economic and sociopolitical power relations in the second half of the last century. The neoliberal approach is illustrated with Chile’s health sector reform in the 1980s and the Colombian reform since 1993. The comprehensive “public logic” is shown through the social insurance models in Costa Rica and in Brazil and through the national public health systems in Cuba since 1959 and in Nicaragua during the 1980s. These experiences emphasize that health care systems do not naturally gravitate toward greater fairness and efficiency, but require deliberate policy decisions.

The definitive version is available at www3.interscience.wiley.com, Latin American national health systems were drastically overhauled by the health sector reforms the 1990s. Governments were urged by donors and by the international financial institutions to make major institutional changes, including the separation of purchaser and provider functions and privatization. This article first analyses a striking paradox of the far-reaching reform measures: contrary to what is imposed on public health services, after privatization purchaser and provider functions are reunited. Then we compare two contrasting examples: Colombia, which is internationally promoted as a successful--and radical--example of 'market-oriented' health care reform, and Cuba, which followed a highly 'conservative' path to adapt its public system to the new conditions since the 1990s, going against the model of the international institutions. The Colombian reform has not been able to materialize its promises of universality, improved equity, efficiency and better quality, while Cuban health care remains free, accessible for everybody and of good quality. Finally, we argue that the basic premises of the ongoing health sector reforms in Latin America are not based on the people's needs, but are strongly influenced by the needs of foreign--especially North American--corporations. However, an alternative model of health sector reform, such as the Cuban one, can probably not be pursued without fundamental changes in the economic and political foundations of Latin American societies.

To the Editor: A serosurvey was conducted in Durba, a mining village near Watsa, northeastern Democratic Republic of Congo, the epicenter of Marburg hemorrhagic fever (MHF) outbreaks in 1994 and 1998–2000 (1–3). In this survey, Bausch et al. found a prevalence of anti-Marburg immunoglobulin (Ig) G of 0.35% (2 of 565) in the nonmining population, but a prevalence of 3.75% (13 of 347) in miners. Mine work was an independent risk factor for seropositivity for anti-Marburg IgG (1). Given that widespread secondary transmission could not be documented in the seropositive miners, primary transmission from the unknown reservoir likely occurred in the mines where rodent, shrew, bat, and other fauna were abundant. No evidence of Marburg virus (MBGV) infection was found in samples from small mammals, amphibians, and arthropods collected in and around Gorumbwa mine (R. Swanepoel, pers. comm.); the origin of the MHF outbreak remained unknown. We hypothesized that the MBGV reservoir's habitat might not be limited to gold mines around Durba, but may exist in caves or forests in the wider Watsa area. As hunter-gatherers, pygmies enter caves for shelter and are in frequent contact with wild animals and body fluids of butchered game. Earlier studies found that pygmies were seropositive for filoviruses significantly more often than subsistence farmers (for filoviruses [4,5], for Ebola but not Marburg [6]). We conducted a seroprevalence study to verify whether pygmies living in the Watsa area constitute another population at risk for primary transmission of MBGV. The Watsa area's population (≈180,000) includes 4,000 pygmies living predominantly in its southern parts (1). The pygmies live seminomadically in the forest, occasionally leaving to exchange goods with the sedentary Bantu population. We invited the pygmy population to meet with our study representatives at sites 50–90 km from Durba. Three hundred persons volunteered during a 5-day period. After informed verbal consent was obtained, the study participants were interviewed, and a blood sample was taken from each volunteer. For operational reasons, we excluded children

Summary In this paper, we present a framework for analysing the complex relationship between disease control programmes and basic health care systems. Many of the ideas and concepts presented in this paper were developed by the staff of the Public Health Department of the Antwerp Institute of Tropical Medicine (ITM) over the last 20 years. They are thus the product of the reflection of an entire team.

The European Union claims that the defense of its welfare state is one of today's most important challenges. This article analyzes whether the European governments and the European Union really pursue a policy that strengthens their health and social security systems, or one that is in itself a threat to health and social security. After a summary of the origin and evolution of the European health systems, the authors pinpoint underlying reasons for reform and demonstrate how, since the 1990s, the European Union has built a strict financial and political straitjacket, forcing these systems to carry out privatization and cutbacks. Reform measures can be divided into three interdependent categories: (1) the increasing influence of governments on health care organization, to enable restructuring; (2) measures aimed at reducing public expenses, including higher financial contributions by patients and restrictions on the range of services provided; and (3) measures that establish competition and hidden or open privatization of services and insurance systems. Through these mechanisms public expenses are reduced while private health care expenses (and private profits) rise freely. Ongoing European health care reforms thus struggle with the contradictions between responding to growing collective needs and securing or increasing private profits.

An exploratory study was conducted in the rural Estie district of Ethiopia in 1997 to identify the role of ABO blood group, rhesus factor, and type of grass pea (Lathyrus sativus) diet in the susceptibility to neurolathyrism. Five-hundred study subjects (250 cases and 250 controls) were examined and interviewed, and had their ABO and rhesus blood groups determined. The majority (86%) of the cases were males. Blood group O was the most common in the patients and controls followed by groups A, B, and AB. The vast majority of the study subjects were rhesus-positive. The gravy (Shiro) grass pea preparation was consumed by 91.6% of the study population, boiled (Nifiro) by 86%, and roasted (Kollo) by 56.4%. Almost half (48%) of the cases had consumed grass pea for > 4 months compared to 8% of controls (P < 0.001). There was a significant association between the risk for neurolathyrism and the consumption of boiled (adjusted odds ratio [AOR] = 98.4) and roasted (AOR = 55.62) forms of grass pea. There was no risk of paralysis associated with consumption of the gravy form of grass pea (AOR = 0.40, 95% confidence interval 0.1-2.0). Blood group O remained significantly associated with the disease after adjusting for age, type of grass pea preparation consumed, and duration of consumption (AOR = 2.90).

A noteworthy cluster of six cases of Marburg haemorrhagic fever (MHF) was identified in the Democratic Republic of Congo. One of the cases is the first infant Marburg fever patient ever documented. Three of six cases presented surprisingly mild symptoms. The results of epidemiological and virological investigations are compatible with person-to-person transmission through body fluids and with mother-to-child transmission while nurturing. The findings show that mild cases of MHF have to be expected during an outbreak and point out the difficulty to base patient management decisions on clinical case definitions alone.

Objectives Cross-sectional studies have shown a strong association between Mycoplasma genitalium and HIV infections. We previously reported that in a cohort of female sex workers in Uganda, M genitalium infection at baseline was associated with HIV seroconversion. Here we examine the temporal association between the M genitalium infection status shortly before HIV seroconversion and HIV acquisition. Methods A nested case-control study was conducted within a cohort of women at high risk for HIV in Kampala. Cases were those of women acquiring HIV within 2 years of enrolment. For each of the 42 cases, 3 controls were selected from women HIV negative at the visit when the corresponding case first tested HIV seropositive. The association between HIV acquisition and M genitalium infection immediately prior to HIV testing was analysed using conditional logistic regression. Results There was weak evidence of an association between M genitalium infection and HIV acquisition overall (crude OR=1.57; 95% CI 0.67 to 3.72, aOR=2.28: 95% CI 0.81 to 6.47). However, time of M genitalium testing affected the association (p value for effect-modification=0.004). For 29 case-control sets with endocervical samples tested 3 months prior to the first HIV-positive result, M genitalium infection increased the risk of HIV acquisition (crude OR=3.09; 95% CI 1.06 to 9.05, aOR=7.19; 95% CI 1.68 to 30.77), whereas there was little evidence of an association among the 13 case-control sets with samples tested at an earlier visit (crude OR=0.30: 95% CI 0.04 to 2.51; aOR=0.34; 95% CI 0.02 to 5.94). Conclusions Our study showed evidence of a temporal relationship between M genitalium infection and HIV acquisition that suggests that M genitalium infection may be a co-factor in the acquisition of HIV infection.

This paper reports a randomised, double-blind, placebo-controlled clinical trial of the effect of routine vitamin A supplementation given on admission to children with severe malaria with regard to survival, recovery during hospitalisation and outcome 6 weeks after discharge. Children aged between 6 and 72 months admitted to the paediatric wards of the Central Hospital of Maputo (CHM), Mozambique with a diagnosis of severe malaria were randomly assigned either to a control group (placebo) or an experimental group (vitamin A) and were followed up 6 weeks after discharge. There were 280 children in the experimental and 290 in the placebo group. Seven (2.5%) and 13 (4.5%) children died in the experimental and the placebo groups, respectively, a relative risk of death of 0.56 (95% CI 0.23-1.38, p = 0.201). During the 1st 5 hours of admission, the relative risk of death in the vitamin A-supplemented group was 2.54 (0.50-12.96); after 5 hours of admission it was 0.19 (95% CI 0.04-0.85; p = 0.015). In the supplemented group, 4/82 (4.9%) of the children developed neurological sequelae vs 2/78 (2.6%) in the placebo group (RR = 1.90; 95% CI 0.36-10.09; p = 0.682). Although the overall reduction in the risk of death observed for all children receiving vitamin A is not statistically significant, it might be clinically important. This finding cannot, however, be accepted as a firm conclusion and requires validation by future trials.

We review methods for analysing the performance of several diagnostic tests when patients must be classified as having a disease or not, when no gold standard is available. For latent class analysis (LCA) to provide consistent estimates of sensitivity, specificity and prevalence, traditionally `independent errors conditional on disease status' have been assumed. Recent approaches derive estimators under more flexible assumptions. However, all likelihood-based approaches suffer from the sparseness of tables generated by this type of data; an issue which is often ignored. In light of this, we examine the potential and limitations of LCAs of diagnostic tests. We are guided by a data set of visceral leishmaniasis tests. In the example, LCA estimates suggest that the traditional reference test, parasitology, has poor sensitivity and underestimates prevalence. From a technical standpoint, including more test results in one analysis yields increasing degrees of sparseness in the table which are seen to lead to discordant values of asymptotically equivalent test statistics and eventually lack of convergence of the LCA algorithm. We suggest some strategies to cope with this.

The objective of this study was to test the potential of routine vitamin A supplementation at admission to speed up recovery during hospitalization for acute lower respiratory tract infections (ALRI) and to decrease the levels of morbidity at 6 weeks after discharge. The study was conducted in the Central Hospital of Maputo (CHM), Mozambique, from 1995 to 1997.Children aged 6-72 months with ALRI admitted to the paediatric wards of the CHM were assigned to a supplementation group (n = 71, receiving 200000 IU of vitamin A) or a control group (n = 93, receiving a placebo).The prevalence of vitamin A deficiency was very high and similar between the two groups. The median number of inpatient days for the supplementation group was 3, for the placebo group 4 days. On day 5 the rate of clinical discharge was 88.4% (n = 61/69) in the experimental intervention group and 73.9% (n = 65/88) in the placebo group (P = 0.023). CONCLUSION We found a statistically significant reduction in duration of admission among vitamin A-supplemented children with ALRI. This effect is in line with what is known about the role of vitamin A in human defence and immune mechanisms and with the serological evidence of the extent of vitamin A deficiency among the children in this trial.

For decades, two opposing logics dominate the health policy debate: A comprehensive health care approach, with the 1978 Alma Ata Declaration as its cornerstone, and private competition logic, emphasizing the role of the private sector. We present this debate and its influence on international health policies in the context of changing global economic and sociopolitical power relations. The neoliberal approach is illustrated with Chile's health sector reform in the 1980s and the Colombian reform since 1993. The comprehensive 'public logic' is shown through the social insurance models in Costa Rica and in Brazil, and through the national public health systems in Cuba since 1959, and in Nicaragua -during the 1980s. These experiences emphasize that health (care) systems do not naturally gravitate towards greater fairness and efficiency, but that they require deliberate policy decisions.

the population's knowledge is important to develop participatory processes that support the reduction of Aedes aegypti.to identify sociodemographic factors, knowledge, perceptions and practice in the population of three people's councils in Lisa municipality about Aedes aegypti control and dengue prevention; to determine the association of these sociodemographic factors with the adequate level of knowledge about dengue, and relate the implementation of suitable practice to risk knowledge and perceptions.cross-sectional study was conducted in which surveys and an observational guide were applied to a randomized sample of individuals living in the selected areas. Percentages from the people's councils were compared whereas two logistic regression models to set relations among the studied variables were adjusted for.the most cited breeding site for Aedes aegypti was garbage (67.3%), the most referred preventive measure was container covering (90.2%); perception of risk of getting sick was low or non-existent (55%); regarding the visited houses, the most used practices were cleaning of backyards and water tank protection. In the multi-variate analysis, the young people showed better knowledge than people aged over 59 years whereas those people having better knowledge of breeding sites and preventive measures were the ones who followed adequate practice.it was demonstrated that adequate knowledge on dengue and its vector are related to better implementation of suitable preventive measures in the house; however, specific aspects on breeding sites should be taken into consideration within the educational programs carried out in each locality.

The percentage increase or reduction of the number of cases of tuberculosis and the incidence rates in the periods 1992-1994 and 1994-2002 were estimated. Of the total of 11,216 cases, 9737 (86.8%) were pulmonary tuberculosis, among them 30.5% with negative smear. Only 1 279 cases (13.1%) of smear-negative culture-positive pulmonary tuberculosis were registered. 13.2% cases had extra pulmonary tuberculosis. There was an increase from 7.2 to 14.7 per 10(5) inhabitants that accounted for 24.1% in the global rate of tuberculosis incidence of 1994 compared with 1993, and of 53% in comparison with 1992 (5.8 to 14.7 per 10(5) inhabitants). A sustained reduction of 48.3% (6% per year) was observed from 1994 to 2002, but the proportions of the case categories were relatively stable. An important growth of the number and the rate of cases with smear-negative pulmonary tuberculosis reported in the period 1992-1994 and a sustained decrease between 1995 and 2002 very possibly associated with the strengthening of the control measures were noticed.

We evaluated the diagnostic yield of fiberoptic bronchoscopy for the diagnosis of smear-negative pulmonary tuberculosis in patients treated at a referral hospital in Lima, Peru. Of the 611 patients who underwent the procedure, 140 (23%) were diagnosed with tuberculosis based on the analysis of BAL samples. Being young and being male were significantly associated with positive cultures. In addition, 287 patients underwent post-bronchoscopic sputum smear testing for AFB, the results of which increased the diagnostic yield by 22% over that obtained through the analysis of BAL samples alone. We conclude that the analysis of BAL samples and post-bronchoscopic sputum samples provides a high diagnostic yield in smear-negative patients suspected of having pulmonary tuberculosis.

During the 1990s, Cuba was able to overcome a severe crisis, almost without negative health impacts. This national retrospective study covering the years 1989-2000 analyses the country's strategy through essential social, demographic, health process and health outcome indicators. Gross domestic product (GDP) diminished by 34.76% between 1989 and 1993. In 1994 slow recuperation started. During the crisis, public health expenses increased. The number of family doctors rose from 9.22 to 27.03 per 104 inhabitants between 1989 and 2000. Infant mortality rate and life expectancy exemplify a series of health indicators that continued to improve during the crisis years, whereas low birth weight and tuberculosis incidence are among the few indicators that suffered deterioration. GDP is inversely related to tuberculosis incidence, whereas the average salary is inversely related to low birth weight. Infant mortality rate has a strong negative correlation with the health expenses per inhabitant, the number of maternal homes, the number of family doctors and the proportion of pregnant women receiving care in maternal homes. Life expectancy has a strong positive correlation with health expenses, the number of nursing personnel and the number of medical contacts per inhabitant. The Cuban strategy effectively resolved health risks during the crisis. In times of serious socio-economic constraints, a well conceptualized public health policy can play an important role in maintaining the overall well-being of a population.